Paget Disease of Breast — SCE Dermatology MCQ

Correct answer: D — Biopsy of the affected area

A) Biopsy of the affected area is correct. A unilateral, persistent, eczematous change of the nipple and areola that fails to clear after an adequate trial of topical steroid and antifungal therapy is the classic clinical description of mammary Paget's disease, and this diagnosis cannot be excluded on inspection alone. Paget's disease represents intraepidermal spread of an underlying ductal carcinoma (in situ or invasive) in the great majority of cases, so failure to respond to eczema treatment is a red flag, not a sign that a stronger cream or different agent is needed. UK dermatology and breast cancer pathways treat this presentation as suspected malignancy until proven otherwise, and histological (punch or incisional) biopsy of the nipple skin is the only investigation that can confirm or refute Paget cells and guide urgent referral for breast imaging and oncological work-up. Delay in biopsy directly delays cancer diagnosis and worsens prognosis, since outcome depends on the extent and invasiveness of the underlying tumour. Why the other options are wrong: B) Change to topical Tacrolimus: this simply substitutes one anti-inflammatory agent for another and would mask or partially settle the eczematous appearance without addressing the possibility of underlying malignancy, delaying diagnosis further. C) Reassure and review in 3 months: unresponsive unilateral nipple eczema after six weeks of appropriate treatment already meets the threshold for urgent tissue diagnosis; a further period of watchful waiting is inappropriate and dangerous given the malignant differential. B. Increase corticosteroid potency: escalating steroid strength assumes the diagnosis is inflammatory dermatitis, which has already been excluded by treatment failure, and stronger steroids will not treat an underlying carcinoma. C. Prescribe oral antibiotics: there are no features here (purulent discharge, cellulitis, systemic signs) suggesting bacterial infection, and antibiotics have no role in a non-infective, non-resolving eczematous nipple lesion. Key point: unilateral nipple/areolar eczema that persists despite adequate topical treatment must be biopsied to exclude Paget's disease of the breast, not treated more aggressively as eczema.

Reference: Patient.info (Professional), "Paget's Disease of Breast", citing NICE guidance on management of Paget's disease of the nipple, reviewed 2023, https://patient.info/doctor/pagets-disease-of-breast